Miguel had struggled to get to the United States from El Salvador to make a better life for himself. He had been here for 2 years, working for a landscape company, when he started noticing bruises and constant fatigue. A severe nosebleed eventually sent him to the emergency room.

A presumptive diagnosis of acute leukemia was made after preliminary blood tests. Miguel did not know what to do—he had no money, no insurance, and no legal papers. He was here illegally. In spite of that, the hospital admitted him, confirmed the diagnosis, and began treatment, but over the next few months, it became obvious Miguel’s leukemia would take his life. He was here alone—his family was back in El Salvador, too afraid to try and travel the long and winding journey through Guatemala and Mexico to the United States. Back home Miguel left his mother, sister, 3 brothers, and 2 grandparents. He was here to make a better life for himself, and to send what little money he could back home to try and improve his family’s life. As with most illegal immigrants, he hoped to one day bring his family to the United States.

But now he lay in a bed, treatments exhausted, and death lurking in his body. As he looked out the window, his face grimaced with a want for his homeland.

I was consulted to discuss goals of care and discharge options now that there were no more curative treatments—even palliative chemotherapy was not recommended. I introduced myself, and sat down to speak with Miguel in the presence of an interpreter. As I usually do, I asked Miguel to tell me about himself and his family.

His eyes dimmed as he told me about life in El Salvador, a tough life with hunger the norm rather than the exception. His house was small, with 3 rooms for 7 people; in fact, it was so small, he slept in one bed with his 3 brothers. But he also spoke of the love for his mother, a girlfriend he never married, and why he came to the United States. He also told me about the underbelly of illegal immigration, the trip through Mexico that takes the hopes and lives of many immigrants.

It took Miguel 12 attempts to get to the United States. Getting through Guatemala, while difficult, was nothing like getting through Mexico he said.

“Do you want to tell me what happened?” I asked.

“There are gangs, bandits, police, immigration, they all want to catch you. And unlike here, many of the police are corrupt and ruthless, especially in the frontera, the border between Guatemala and Mexico.”

He stopped for a while, then spoke again.

“I was beaten, robbed, almost killed—left for dead by the train tracks. If the bandits and gangs don’t get you, the police and immigration will. After crossing into Mexico, I was beaten by bandits—I had nothing to give because I had to bribe the police in Guatemala. So when I had nothing, I was beaten. They surrounded me on the top of one of the train cars, and they beat me, over and over. But I was lucky, I lived because I jumped from the train. The gangs and bandits are on the trains—the trains are the way we cross Mexico—and the gangs and bandits act like they’re illegals too, but they’re just choosing who to beat, rob, rape, and kill.”

He hung his head.

“I saw girls raped, young girls, raped by 5 to 6 men, then beaten. I heard stories many were killed after being raped. But there is no one to help, if you go to the police or immigration, they can send you back home, or they will rob and beat you. You’re there illegally, so we never report the beatings or the rapes, we just want to get to the United States.”

He took a long breath and continued.

“But if you can get by the frontera and through the state of Chiapas, you have a chance. You have a chance. But you can still be caught. Once I was almost to Texas and got caught. I cried, I did not want to go through the frontera again, but I had to, I wanted to be in the United States.”

He paused, then looked up at me: “I love the United States.”

Miguel told a story that I am certain could be repeated hundreds of times every day. The want of a magical life in the United States is overwhelming when one lives in poverty and sees snippets of our life on television, so doing whatever it takes to get here is worth the chance, even the chance of losing your life.

I didn’t know what to say to Miguel, for there was much to say, yet little to say. He had placed his life in danger to get to the United States, only to arrive here and meet a disease more deadly than bandits and gangs. And with leukemia, you can’t be deported and start over again. This was it, death was certain. We spoke of the things palliative care doctors speak of: how would he want to die, would he want resuscitation, did he have any semblance of an advance directive, had he notified his family of his illness, and did he want to try and get home to El Salvador? He answered. He wanted to die in comfort, he did not want resuscitation, he did not have an advance directive though Carlos who worked at the landscaping business would be his choice for a power of attorney, his family knew he was sick but not that he was dying, and yes, he wanted to go home. He really wanted to go home. We worked on all of that, including speaking to his family and getting him back home to El Salvador.

I never asked Miguel why he didn’t come to the United States legally, but I assumed he did not have the money to obtain legal status, and with a 7th grade education, his skills were likely considered less valuable than other immigrants, so getting here illegally seemed the only option.

But Miguel left an impression on me. Every minute of every day, there are Miguels walking the back roads of despair and riding the trains of Mexico, trying to get to the United States, trying to reach the land of promise. There are also Miguels being beaten, robbed, raped, and killed, and far-too-often victimized by those sworn to protect them. So without stepping into the political quagmire of illegal immigration, I simply ask that we remember all of these immigrants are just like Miguel, with families and feelings and the want of opportunity. They are fathers, sons, mothers, daughters, husbands, wives, and brothers and sisters—just like you and me.

Yet I am not naïve. I know that the blame of illegal immigration does not lie with the United States, but rather with the economic and sociopolitical conditions of the countries from which these immigrants come. Similarly, I know that the resolution of illegal immigration is complex and complicated and will not be simple and easy. But surely there has to be a better way to solve this heartrending separation of families, as well as the untold human suffering that occurs during the long and treacherous journey to the United States. There just has to be.

But for Miguel, who longed for a life in the United States, it was not to be. Per his wish, he was provided transport back home to El Salvador, to be surrounded by family and friends as he breathed his final breath. But this time, the journey was without bandits and gangs, and without beatings and robberies.

Watch and share this five minute video about the need for prophylactic end-of-life conversations. Laura Heldebrand, an ICU nurse tells her mother's story.

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